Provider Demographics
NPI:1063479020
Name:BODE, GEORGIA KONSTANDOPOU (MD)
Entity type:Individual
Prefix:
First Name:GEORGIA
Middle Name:KONSTANDOPOU
Last Name:BODE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 3999
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90510-3999
Mailing Address - Country:US
Mailing Address - Phone:310-792-3914
Mailing Address - Fax:310-792-3802
Practice Address - Street 1:4060 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90023-2526
Practice Address - Country:US
Practice Address - Phone:323-268-5514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40295207L00000X, 208VP0000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A402950OtherBLUE SHIELD
CA00A402951Medicaid
CA00A402951Medicaid
CA00A402950OtherBLUE SHIELD